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General NPI Number Information
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NPI Number | 1699810069
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Entity Type | Organization
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Legal Business Name | EAR NOSE AND THROAT SURGICAL GROUP
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Dates
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Enumeration Date | 02/21/2007
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Last Update Date | 08/10/2011
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Provider Practice Location Address
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Address Line | 970 LAKELAND DR STE 40
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City | JACKSON
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State | MS
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Zip | 39216-4640
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Country | US
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Telephone | 601-200-4850
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 23666
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City | JACKSON
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State | MS
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Zip | 39225
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Country | US
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Telephone | 601-200-4850
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Fax | 601-200-4838
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Authorized Official
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Title or Position | PHYSICIAN
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Name | MICKEY P WALLACE
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Credential | MD
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Telephone | 601-898-7000
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number | 08819
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License Number State | MS
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